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Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center
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Urethral Obstruction in Women Prevalence: 2 - 29% of women with persistent LUTS Symptoms: – storage 29% – emptying 8% – both 63%
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Diagnosis Urodynamics (synchronous pdet / Q) Cystoscopy
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Urethral obstruction High detrusor pressure (pdet > 20 cm H 2 0) Low uroflow (Qmax < 12 ml/S)
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Impaired Detrusor Contractility Weak & or poorly sustained detrusor contraction (pdet < 20 cm H 2 0) Low flow (Qmax < 12 ml/S)
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Blaivas - Groutz Nomogram
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Diagnosis ”…radiographic evidence of obstruction…in the presence of a sustained detrusor contraction.” No specific UDS criteria Obstructed women had: –lower Qmax –higher Pdet@Qmax –higher PVR 23% of 331 women were obstructed Nitti et al., 1999:
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Etiology Groutz et al., 2000; Nitti et al., 1999 Prior surgery 14 - 30% Prolapse 29% Stricture 15% 1 O bladder neck obstruction 10 - 16% DESD 6% Learned Voiding Dysfunction 6 - 33% Urethral diverticulum 4%
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Urethral Obstruction in women Anatomic Functional
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
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Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
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MSCO High pressure Low flow
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Blaivas - Groutz Nomogram
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy
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Pdet @ Qmax = 36cm H2O Qmax = 8.3ml/S
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Blaivas - Groutz Nomogram
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Pdet @ Qmax = 54 cm H2O Qmax = 2 ml/S,
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Blaivas - Groutz Nomogram
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy
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FS pdet@Qmax = 68 cm H 2 0 Qmax = 5 ml/S Tic
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Blaivas - Groutz Nomogram
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
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JTJT JT pdet@Qmax = 80 cm H 2 0 Qmax = 5 ml/S
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Blaivas - Groutz Nomogram
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
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JTJT JT pdet@Qmax = 75 cm H 2 0 Qmax = 8 ml/S Urethral obstruction
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Blaivas - Groutz Nomogram
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
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Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy
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RSN pdetmax = 90 cm H 2 0 Qmax = 7 ml/S
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Blaivas - Groutz Nomogram
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Anatomic Urethral Obstruction: Treatment Intermittent catheterization Surgery - depends on the cau se: –correct prolapse –sling incision / urethrolysis –urethral diverticulectomy
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Surgical Rx of Stricture Urethral dilation Urethrotomy Urethroplasty
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Buccal graft
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Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior
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2 Strss pdet@Qmax = 150 cm H20 Qmax = 1 ml/S
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Blaivas - Groutz Nomogram
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Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior
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PS Involuntary detrusor contraction Involuntary sphincter contraction Obstruction due to sphincter contraction
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CG Involuntary detrusor contraction Involuntary sphincter contraction Vesical neck obstruction
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Blaivas - Groutz Nomogram
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Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior
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Detrusor contraction Sphincter contraction Low flow Obstruction by sphincter
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Functional Urethral Obstruction: Treatment Primary vesical neck TUI / TUR of vesical neck ? Alpha adrenergic antagonists Neurogenic Intermittent catheterization +/- anticholinergics, Botox, Neuromodulation, enterocystoplasty Acquired behavior Bmod / biofeedback
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Impaired Detrusor Contractility Low flow Weak or poorly sustained detrusor contraction Pressure flow criteria: –Qmax < 12 ml/s –Pdet@Qmax < 20 cm H2O –Wmax < 10 Groutz et al., 2000
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amb pdetmax = 10 cm H 2 0) Qmax = 8 ml/S
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Impaired Detrusor Contractility: Etiology Neurogenic –Thoracic, lumbar & sacral lesions –Diabetes mellitus Myogenic –Primary / idiopathc –Urethral obstruction –Bladder overdistension Urethral obstruction Post-surgical –Ischemia Groutz et al., 2000
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Impaired Detrusor Contractility: Treatment Observation Double voiding Timed voiding Intermittent catheterization ? Medications –Cholinergic agonists –Alpha adrenergic antagonists Neuromodulation
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Conclusion Urethral obstuction not uncommon Prevalence: 2 - 29% of pts with LUTS Symptoms – non-specific –irritative 29% –obstructive 8% –both 63% Diagnosis based on p/Q studies Rx based on underlying cause
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